A grandma who choked to death while eating cheese on toast was ‘not adequately monitored’ by care home staff in line with the care plan, a coroner has ruled.
Yvonne Grainger died on November 13, 2021, in hospital. She had been rushed there by paramedics the day before after she began choking on her evening meal, Manchester Coroners Court heard on Wednesday (May 24).
Yvonne, a 76-year-old grandmother, had been a resident at the Seymour Care Home, on North Road in Clayton, for just under a fortnight when the tragic incident occurred. Her family said she was ‘taken way too soon', adding they will 'miss her hugs and giggles’.
READ MORE: Join the FREE Manchester Evening News WhatsApp community
A pre-assessment care plan was put in place for Yvonne after she moved in on November 1, care home staff said. In the initial plan, a reference was made to Yvonne having ‘issues’ with eating, namely coughing while she tried to swallow.
That prompted staff to make a referral to the Speech and Language Therapy Team (SALT) over her difficulties swallowing. However, a formal assessment was not carried out before she died.
After Yvonne moved in, care home staff then began drawing up a full care plan, which contained reference to her needing softer foods, and requiring ‘monitoring’ during mealtimes, as well as ‘encouragement’. However, this care plan was never completed before Yvonne died - so it was never ‘printed off’, according to care home manager Michelle Mansfield.
“The care plan was not active,” she told coroner Zak Golombeck. “It only got printed off after DS Kelly (from the police) asked for it.”
Ms Mansfield then accepted ‘a softer [food] option would have been better’ for Yvonne, instead of the cheese on toast she was served at 4.30pm on November 12. At the time, she was being cared for by senior carer, Elaine Myerscough.
A written log of CCTV, read out by Mr Golombeck, said that as Yvonne ate her meal, Ms Myerscough was handing out medication to other residents, so left the lounge where Yvonne was. When she returned, Yvonne’s head was tilted back, and Ms Myerscough checked on her condition — and then called 999.
Ms Myerscough accepted that the monitoring of Yvonne was not adequate, when asked by the coroner. She said: “No. On that evidence [it was not adequate].
“I was giving medication at the time and the girls [other care home staff] were giving meals out. Somebody should have been with her.”
A post-mortem identified the primary cause of Yvonne's death as 1A, laryngeal obstruction, with a secondary cause being vascular dementia. Since the incident, Ms Mansfield said ‘procedures’ at Seymour Care Home had been ‘updated’ and ‘strengthened’.
Mr Golombeck said he would review the new care home procedures before making a final call on if a section 28 prevention of future deaths report should be commissioned.
The coroner recorded a narrative conclusion that ‘Yvonne Grainger died following accidental choking where the deceased was not monitored as per the care plan in place’.
In summarising his findings, he said: “Yvonne Grainger moved to Seymour Care Home on November 1, 2021. Prior to her moving, there had been a pre-admission assessment which referred to some issues relating to her eating and drinking.
“Upon her admission there was reference to a care plan document that was partially completed for Yvonne Grainger having a reference for softer foods and requiring monitoring and encouragement during meals. There had not been a formal SALT assessment with respect to eating and drinking.
“There was a reference for softer foods and information being passed to the care home on Yvonne being able to make her own choices on meals. There had not been any incidents prior to November 12 with respect to choking.
“The care records do not refer to any issues at meal times. I have considered carefully the meal choices that were available to residents and those choices which were made by Yvonne. It does appear that the majority were softer foods that were available to her.
“On November 12, it’s clear that Yvonne opted for her evening meal to have cheese on toast. It was accepted in evidence that this is not necessarily a soft food. Nevertheless, with respect to not being on a prescription [for] food [it was] not necessarily inappropriate.
“However, I do find there was not adequate monitoring of Yvonne during the evening meal. It’s clear that was not appropriate monitoring as per the contents of the care plan in place.
“What transpired was that Yvonne choked on cheese on toast and as a result, she suffered laryngeal obstruction.
“This was contributed to by her vascular dementia, although it must be reiterated there had been no SALT therapist who had reviewed Yvonne in order to make a final determination on food she should have. As a result of the incident, staff phoned the emergency services and she was admitted to Manchester Royal Infirmary where she sadly died on November 13, 2021.
“A post mortem fund that [Yvonne] died from laryngeal obstruction from food material due to vascular dementia. I accept the case [of death] that is offered.
“It’s clear from the evidence that Yvonne died from an accident, however, I also find that there was a contribution with respect to the lack of monitoring. I also have a duty of a prevention of deaths report with regards to systems in place. I am going to reserve judgement and ask Michelle Mansfield to send all information on changes made to the updates procedures. Then a final decision can be made.”
Following the hearing, Yvonne's family paid a touching tribute to their late mum. They said: "Yvonne was a very special mum to Francine, Nick (who is now deceased), and Melissa.
"She was also a caring daughter, grandma, sister, mother in law, sister in law and friend. She devoted her life to meeting our needs and making sure we knew how much she loved us. She was taken way to soon and we miss her hugs and giggles. She will always be in our hearts, thoughts and memories. We love you always mum."
A spokesperson for the care home said: "At the time of the incident, the home was following then current COVID protocols whereby our residents and a support staff member were assigned to their own bubble and a communal living area. The choking incident took place when the assigned staff member had stepped away to the nearby kitchen to bring meals to their assigned residents, leaving the room unmonitored for that period of time.
"Meal times have been subsequently reviewed whereby residents that require assistance and monitoring are encouraged to dine in the dining room or at a staggered time, where a member of staff is present at all times. Staff have been given additional clarity in respect of their role for meal-time monitoring that is required due to identified risk factors.
"Administration documents have been updated to ensure the home is provided with additional details around eating and drinking before admission of all new residents and a more rigorous choking assessment has been conducted for all current residents."
Read more of today's top stories here
READ NEXT:
